Leave margin clear For physician notes Division of Developmental and Behavioral Pediatrics North Shore-LIJ Health System / Children’s Health Network Parent Questionnaire The information you provide will help us evaluate your child. Please answer all questions to the best of your ability. If you don’t have particular information, write “don’t know.” Be sure to complete both sides of each page. If you need more space for any question, use the last page of this packet. Child’s Name _____________________________ Sex ______ Birthdate ___________________ Address ________________________________________________________________________ (Number and street) (City/State) (Zip) Mother’s Name Father’s Name Street Address Street Address City, State Zip City, State Zip Home Phone Home Phone Work Phone Work Phone Alternate Phone Alternate Phone Referring Pediatrician Phone Address Reason for Consultation In a few words tell us what questions you or your pediatrician would like us to try to answer for you. If you need more room feel free to use the additional space on the last page to tell us more about your child and the concerns you may have: School History Name of child’s current school City/Town Is this school: Type of program: Public Private or Parochial Present grade in school Regular classroom Self-contained special education classroom Early Intervention (under age 3; center-based or in home) Other: Leave margin clear For physician notes Child’s name ________________________________ (page 2) Check additional services child currently receives (In school or privately): Inclusion teacher Resource room Remedial reading or math 1:1 aide Speech/language therapy Physical therapy Occupational therapy Counseling in school Applied behavioral analysis (ABA) Private psychotherapy Social skills group ■ Educational tutoring Other List other schools/programs your child has attended, including early intervention services and nursery and preschools. City or Town School/Program Grades attended 1. 2. 3. 4. Has your child ever repeated a grade? Yes Has your child been previously evaluated? Type of Evaluation No If yes, which? Yes No (If yes, provide details below) Year (or Age) Evaluator (name of program or person) Psychological Educational Speech/Language Hearing Ophthalmology (vision) Physical or occupational therapy Auditory Processing Psychiatry Neurology Other (e.g. allergy, orthopedics) Does your child have a current IEP (Individualized Education Plan) for school? If yes, what is your child’s classification for educational purposes? Do you help you child with homework? Observations? Yes No Yes No Child’s name ________________________________ (page 3) What are your educational goals for your child? Are you satisfied with the way the school has met your child’s needs? What do you think they could have done or should do differently? Medical Information Was this child adopted? No Yes At what age? Please list all of birth mother’s pregnancies (List name of child, or indicate if miscarriage or termination of pregnancy. INCLUDE THIS CHILD: Name Sex Year Birthweight Length of Pregnancy (Weeks) 1. 2. 3. 4. 5. During the pregnancy with this child did mother: Yes Have a chronic illness? Take any medications? Drink alcoholic beverages? Use drugs? Spill sugar in urine or have diabetes? Smoke? Have a severe accident? Have any infections or rashes? Have high blood pressure? Have excessive weight gain? Have bleeding or threatened miscarriage? Have amniocentesis / other prenatal testing? Require hospitalization? Have any other medical problems? ■ No Specify: Leave margin clear For physician notes Leave margin clear For physician notes Child’s name ________________________________ (page 4) Birth History: Name of hospital where child was born City Was this a multiple birth (twins, etc.)? If so, describe Did the labor start: Spontaneously Induced No labor Baby was delivered: Head first Feet first By cesarean section Did the baby breathe and cry right away? Yes No Comments about any difficulties with the delivery While the baby stayed in the hospital did he/she: Yes No Comments No Comments Have a heart murmur? Have convulsions or seizures? Have any breathing problems? Have any feeding problems? Require treatment for jaundice? Receive a blood transfusion? Have any infections? Require surgery? Have any other problems? How many days did the baby stay in the hospital? As an infant did the baby: Yes Have any problems feeding? Have colic or cry excessively? Fail to gain weight or grow normally? Seem limp or weak? Seem stiff or have tight muscles? Experience sleep problems? Have a normal activity level? Have tremors or convulsions? Drool after 2 1/2 years of age? Child’s name ________________________________ (page 5) Developmental Milestones: At what age did your child: Smile at you Babble Roll over Use single words meaningfully Sit alone Point to show you things Crawl Put two words together Walk alone Start to feed him/herself Pedal a tricycle Start to dress him/herself Use a bicycle (no training wheels) Start to toilet train him/herself Tie shoes Are there any skills which your child mastered that he/she subsequently lost? Yes No Comment Was child’s development/behavior much different from that of brothers/sisters? Yes Comment Medical History — Hospitalizations: Age Reason Age Reason Age Reason Has your child had any of the following tests? ■ EEG Age when last done Normal Abnormal ■ CT scan or MRI Age when last done Normal Abnormal ■ Genetic testing Age when last done Normal Abnormal ■ Thyroid tests Age when last done Normal Abnormal ■ Other Age when last done Normal Abnormal Present Medications: Name 1. 2. 3. 4. Previous Medications: Name 1. 2. 3. 4. Dose/Times Ages when taken No Leave margin clear For physician notes Leave margin clear For physician notes Child’s name ________________________________ (page 6) Are your child’s immunizations up-to-date? Yes No Medical History (Review of Systems): Does your child have or has your child had any, of the following? No Details/Comments Yes Headaches Trouble seeing Trouble hearing Frequent ear infections Dizziness or fainting spells Meningitis or encephalitis Head injury Seizures or convulsions Tics or nervous habits Sleep problems Frequent pneumonia Asthma Heart defect Urine or kidney infections Trouble chewing / swallowing Frequent nausea or vomiting Frequent diarrhea Constipation Frequent stomach aches Overweight Underweight Excessively dry skin Hair loss Bruises easily Broken bones Any surgical operations Environmental allergies Allergies to medication Serious infections Lead poisoning Family History: Under parents, list names of children in order of birth: Year of Highest grade Birth completed Occupation Father Mother 1. 2. 3. 4. 5. School problems? Child’s name ________________________________ (page 7) Yes No Relationship to Child A birth defect Speech or language delay Hearing loss or deafness Vision impairment or blindness Cerebral palsy Muscle weakness Epilepsy; seizures Learning problems Mental retardation Developmental delay Hyperactivity or ADHD Autism or PDD Anxiety or nervousness Motor or vocal tics Tourette Syndrome Obsessive/compulsive disorder Depression or bipolar disorder Excessive alcohol or drug use Conduct disorder Other psychiatric problems Difficulty with the law Social/Environment: Who lives at home? Are parents living together? Yes No If not, please explain (Separated, divorced, one parent deceased, e.g.) What languages are spoken at home? Are there significant marital conflicts? Yes No N/A Do parents agree on how to discipline child? Yes No N/A Are there significant conflicts between child and parents Yes No N/A Is child easy to discipline? Yes No N/A Are there significant conflicts between child and his/her siblings? Yes No N/A Does child have difficulty getting along with other children? Yes No Does child have difficulty getting along with other adults? Yes No What is your child good at or does he/she enjoy doing? What are his/her positive attributes? Leave margin clear For physician notes Leave margin clear For physician notes Child’s name ________________________________ (page 8) Additional information you want to provide about your child and reason for this consultation: If available, attach photo of child: Name of Person Completing this Form Your relationship to child Today’s Date PLEASE CHECK TO SEE THAT YOU’VE COMPLETED BOTH SIDES OF EACH PAGE, THANK YOU! Include photocopies of previous test reports or other materials that you would like us to review. Reviewed by (Developmental Pediatrician’s Signature)